Custom «Preoperative Fasting» Essay Paper

This paper seeks to explore a clinical practice of preoperative fasting among patients that are set to undergo an operation. It, therefore, uses evidence-based arguments and literature review to analyze, compare, and contrast the past and the current preoperative guidelines in healthcare institutions. It finally provides the guidelines that ought to be used in modern hospitals in order to ensure patients’ health and safety.

Preoperative Fasting

Many decades of studies support health and safety advantages of taking clear liquids, which are rich in carbohydrates few hours prior to surgery or other procedure that requires anesthesia or sedation. Still, clinicians in United States regularly order patients to fast for longer preoperative times. Evidence-based instructions suggest liberalizing preoperative fasting guidelines. To ensure patients health and safety it is imperative that healthcare practitioners abandon old preoperative fasting guidelines and use the contemporary available evidence-based preanesthetic procedures.

Preoperative Fasting and Benefits in Clinical Care

Preoperative fasting is a clinical practice of patient abstaining from fluids and food intake for a certain period before a surgery. This practice is aimed at preventing pulmonary aspiration of contents of stomach during general anesthesia. Aspiration of less than 30-40 ml may cause damage and even result in death during surgery, therefore, fasting helps to reduce the stomach contents volume (Itou, 2012).

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Many factors may lead to aspiration of contents of the stomach. These include anesthesia, obesity, pregnancy, full stomach, difficult airways, emergency surgery, and changed gastrointestinal mobility. Prolonged fasting periods lead to reduced injury if aspiration takes place. Additionally, Surg (2006) asserts that it is vital to administer antacids the night prior and then once in two hours before operation. This is helpful for the reduction of pH levels in the stomach. Therefore, it helps minimize the damage that pulmonary aspiration may cause in case it occurs. H2 receptor blockers must be utilized in risky circumstances and must be taken in similar time intervals as antacids.

Literature Reviewed

Manchikanti, Malla, Wargo and Fellows (2011, pp. 963- 973) argue that the growth and development of the specialty of multiple intervention and interventional pain methods have led to health professionals to consider various measures to be taken before these procedures with comfort and safety. Some of these include inflectional control, preoperative fasting, and sedation. Moreover, more development of different methods and enhanced utilization have made health physicians that encounter patients with chronic, constant pain related to psychological challenges presenting with apprehension and anxiety before undergoing interventional methods. Health professionals regularly advise patients set for an elective procedure or surgery to avoid drinking or anything after midnight on the eve of their procedure, whether their surgery is planned for 7am or 2pm the following day. Inflexible fasting regimens prevail since 1940s to minimize pulmonary aspiration throughout anesthesia. This is the time when Mendelson stated a high occurrence of obstetric anesthesia. Mendelson discovered 66 instances incidences of pulmonary aspiration in 0.15% (44, 016) women undergoing obstetrical anesthesia at New York’s Lying-In Hospital between 1932 and 1945.

Additionally, Manchikanti, Malla, Wargo and Fellows (2011) argue that the basis of ASA guidelines is on studies demonstrate that pulmonary aspiration is an uncommon occurrence in present anesthesia. In addition, there is a slight connection between gastric volume and pH and fasting duration; extended fasting does not guarantee empty stomach; and explicit liquids taken 2-4 hours prior to surgery can minimize gastric volumes. The ASA guidelines distinguish between breast milk, clear liquids, formula, light liquids, formula, and heavy, fatty solids. ASA provides a 2-4-6-8 guideline in which individuals should fast for 2-hours fasting from clear liquids; 4 hours from breast milk; 6-hour fasting from light meals; and 8-hour fasting from heavy or regular meals. Besides, its basis is on another belief that abstinence from fluids or food for 6-8 hours probably empties the stomach and reduces the chances of aspiration. Pulmonary aspiration causes aspiration pneumonia as one of the most feared complications of anesthesia, as it is life threatening. Nevertheless, this is rare in the present-day anesthesia; and thus, do not rationalize inflexible preoperative fasting measures for every patient.

As Crenshaw and Winslow (2008) report, Mendelson suggested denial of oral feedings in labor and recommended that women should empty their stomachs prior to the administration of anesthesia, such as, use of the “finger in throat” technique. After six decades of Mendelson’s report, there has been a dramatic change in anesthetic methods. There have also been numerous studies carried out on the impacts of fasting on gastric contents. The American Society of Anesthesiologists (ASA) issued directions that suggested reducing preoperative fasting period for strong patients of respective ages that undergo elective procedures and surgeries. These guidelines are meant for nurses, physicians, and other medical professionals in charge of patients set to receive regional anesthesia, general anesthesia, or analgesia and sedation. Even though, physicians are the ones that prescribe preoperative fasting periods, nurses are responsible for guiding patients on preoperative fasting, enhancing evidence-based instructions for fasting, and supervising patients for conformity and undesirable impacts. Therefore, it is vital that nurses understand the systematic proofs that sustain open fasting practices and on what to train patients.

As Crenshaw and Winslow (2008) report, Mendelson suggested denial of oral feedings in labor and recommended that women should empty their stomachs prior to the administration of anesthesia, such as, use of the “finger in the throat" technique. After six decades of Mendelson’s report, there has been a dramatic change in anesthetic methods. There have also been numerous studies carried out on the impacts of fasting on gastric contents. The American Society of Anesthesiologists (ASA) issued directions that suggested reducing the preoperative fasting period for strong patients of respective ages that undergo elective procedures and surgeries. These guidelines are meant for nurses, physicians, and other medical professionals responsible for patients set to receive regional anesthesia, general anesthesia, or analgesia and sedation. Even though, physicians are the ones that prescribe preoperative fasting periods, nurses are liable for guiding patients on preoperative fasting, enhancing evidence-based instructions for fasting, and supervising patients for conformity and undesirable impacts. Therefore, it is vital that nurses understand the systematic proofs that sustain open fasting practices and on what to train patients.

Crenshaw (2011) asserts anesthetists and anesthesiologists in United States, Canada, and Europe reviewed their preoperative fasting instructions. This was a result of increasing evidence that fit patient's consuming clear liquids several hours prior to sedation or anesthesia are just as comfortable and safe as those patients that fast 6-8 hours prior to surgery. In 2003, a scientific revision of 22 randomized controlled experiments demonstrated that patients that took clear liquids up to 90 minutes prior to surgery were a less risk of aspiration, vomiting, or other associated morbidity in sedation or anesthesia, despite the volume of liquid consumed.

Itou et al. (2012) investigated rehydration therapy of safety and efficacy for two hours prior to surgery in a randomized controlled medical research. According to the study, gastric content in the Oral Rehydration Solution (ORS) category instantly after anesthesia introduction was not lesser than that in a fasting category, and no substantial distinction, and there was no considerable variation between two categories. The investigation indicated that it was safe to administer rehydration therapy prior to preoperatively. Therefore, it is essential to motivate health professionals ought to use oral rehydration therapy until two-hour prior surgery to uphold the quantity body water, as well as electrolytes, and to enhance the patients relieve.

As per Baril & Portman (2007, pp. 609-616), preoperative fasting is still a confusing and frustrating matter for patients and practitioners respectively. It is vital for practitioners to offer patients proper preoperative guidelines so that they maintain their health and safety. According to the study by Baril and Portman (2007, pp. 609-619), there is a high probability of patients to fast for a prolonged, instead of inadequate amount of time prior to surgery. The study findings showed that the present ASA suggestions, and results from other studies at anesthesia and surgeon committee meetings. Even though, patients should avoid solid foods after midnight on the surgery day, they have permission to ingest clear liquids till four hours prior to their set operation. Furthermore, these results indicate that the latest policy fails to reflect the ASA suggestions since there is a lot of concern to keep operation timetable flexible. Moreover, the study shows that prolonged fasting increases the discomfort and probably the morbidity of operation patients. To reduce the risks relating to inadequate or excessive fasting, patients should clearly understand the reason for fasting and the possibility of serious impacts of excessive fasting. Optimal anesthesia, surgical, and nursing results rely on it.

As per Baril & Portman (2007, pp. 609-616), preoperative fasting is still a confusing and frustrating matter for patients and practitioners respectively. It is vital for practitioners to offer patients proper preoperative guidelines so that they maintain their health and safety. According to the study by Baril and Portman (2007, pp. 609-619), there is a high probability of patients to fast for a prolonged, instead of an inadequate amount of time prior to surgery. The study findings showed that the present ASA suggestions, and results from other studies at anesthesia and surgeon committee meetings. Even though, patients should avoid solid foods after midnight on the surgery day, they have permission to ingest clear liquids until four hours prior to their set operation. Furthermore, these results indicate that the latest policy fails to reflect the ASA suggestions since there are a lot of concerns to keep the operation timetable flexible. Moreover, the study shows that prolonged fasting increases the discomfort and probably the morbidity of operation patients. To reduce the risks relating to inadequate or immoderate fasting, patients should clearly understand the reason for fasting and the possibility of serious impacts of excessive fasting. Optimal anesthesia, surgical, and nursing results rely on it.

Current Guidelines on Preoperative Fasting

According to Crenshaw and Winslow (2008), the main purpose of fasting instructions for healthy patients that are set to undergo elective surgery is to reduce the gastric volumes, while avoiding unessential dehydration and thirst. Dehydration is specifically vital in hot countries. Guidelines must be founded on clinical researchers in surgical patients, but when evidence in inaccessible, on the physiology of gastric emptying and digestion. Although earliest books concerning anesthesia never addressed fasting, in 1883, the renowned surgeon Lister suggested that there must not be solid stuff in the stomach, but the patients must take clear liquid almost two hours prior to surgery. For the next eight decades until 1960s, the majority of the studies proposed a 6-hour fating for solids, as well as 2-3 hour fast for clear liquids.

Early study by Surg (2006) demonstrates that in 1960s, in North America, the preoperative instruction “NPO after midnight” was used to both solids and liquids. Although this concept was widespread, the rationale has disappeared with time. Pulmonary aspiration is one of the famous conditions that lead to anesthetic associated mortality. The concept of 25ml in the stomach as the surrogate indicator for high risk of aspiration is currently questioned. Clinical researchers indicate that 40-80% of fasting patients are in that group, yet the occurrence of pulmonary aspiration is one out of the 10,000. In terms of gastric pressure, human stomach is superfluous organ and can contain up to 1000ml prior to intragastric pressure rises.

According to Manchikanti, Malla, Wargo and Fellows (2011) several anesthesia nations have altered their guidelines and presently suggest that patients should take clear fluids until two hours prior to anesthesia and surgery. Most of the anesthesiologists and practitioners of interventional methods seem to believe that it is safe to fast from midnight. Nevertheless, they deem intensive fasting as both dispensable and stressing due to the development of insulin resistance upon surgery.

According to Itou et al. (2012), in the case of gastric emptying, current physiological investigations employ a dual isotope method in which liquids and solids are labeled with various radioactive isotopes. Clear liquids drain exponentially, 90% in an hour and nearly in two hours. Absolute draining of a meal usually takes about 2-3 hours. Large bits of indigestible food, particularly vegetables that contain cellulose, drain by a distinct method, when the stomach has drained digestible food and liquid, which can take 6 and 12 hours. Therefore, gastric physiology recommends that NPO after midnight is reasonable for solids, but patients can safely take clear liquids on the surgery day. However, entrenched myths, those based on wrong premises, are hard to dislodge. Double blind, randomized clinical experiments in surgical patients were needed.

Preoperative fating is a vital clinical practice that has numerous benefits to the patients, including reduction or trauma, pulmonary aspiration, and other complications. The “NPO after midnight” concept is only applicable to solids for patients set for operation in the morning. An early light breakfast of digestible toast or the same food together with clear liquid is allowed for afternoon surgeries. Clear liquids must be allowed until 3 hours prior to the planned surgery time. This is to ensure that a change in the surgery program can easily be made, and still allows a 2-hour period prior to the real surgery time. In the case of patients having a true gastroesophageal reflux, whether they drink or not, ranitidine (H2-receptor blocker) or omeprazole (proton pump inhibitor) can be appropriate to reduce gastric acid discharge.